If you received a personalized notice in the mail or via email with a Claim ID and Confirmation Code, please enter the codes you were provided below.

Please remember to enter the full Claim ID exactly as it appears on your personalized Notice, (i.e. 12345678).

The deadline for submitting this proof of claim form is

To submit a claim for a pro rata cash payment from this settlement, please complete this form, sign where indicated, and submit.

Your Contact Information

* Required Fields

Payment Method

You have successfully requested a payment. Click here if you would like to choose a different payment method.

Signature

By submitting this claim form, I declare that I believe I am a member of the Settlement Class and that I consent to the use of this information to process my claim.

Your Claim Form has been submitted successfully.

Please print this page for your records.

Your Claim Details
Submitted Claim ID:
Confirmation Code:
You will need the above Submitted Claim ID and Confirmation Code if you would like to edit your Claim at a later time, so please print this page for your records.
CLAIM INFORMATION
First Name
Last Name
Street Address
Street Address 2
City
State
Province
Zip Code
Postal Code
Country
Email Address
Phone Number
Signature
Date

If you have any questions regarding your Claim, please provide the Submitted Claim ID listed above and email us at Questions@PlushCareAutoRenewSettlement.com

Click here to edit your Claim.

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